ID

16966

Description

ODM derived from: http://research.uic.edu/qip/toolbox/case-report-forms-crf. Template Name: Prior and Concomitant Medications. QIP Case Report Forms, UIC Quality Improvement CRF, Office of the Vice Chancellor for Research. Center for Clinical and Translational Science, UIC University of Illinois at Chicago.

Link

http://research.uic.edu/qip/toolbox/case-report-forms-crf

Keywords

  1. 8/17/16 8/17/16 -
Uploaded on

August 17, 2016

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Prior and Concomitant Medications: UIC Quality Improvement CRF

Prior and Concomitant Medications: UIC Quality Improvement CRF

General Information
Description

General Information

Protocol Title
Description

Protocol Title

Data type

text

Site Number
Description

Site Number

Data type

integer

Subject ID
Description

Subject ID

Data type

integer

Visit Date
Description

Visit Date

Data type

date

Were any Concomitant medications taken by the subject ___ days before or during the study? If Yes, record below.
Description

Prior and Concomitant Medications

Data type

text

If yes, how many days before?
Description

Prior and Concomitant Medications

Data type

integer

Prior and Concomitant Medications: No
Description

Prior and Concomitant Medications

Data type

boolean

Medications
Description

Medications

Medication
Description

Medication

Data type

text

Dose
Description

Dose

Data type

text

Route (see Description)
Description

1= oral 2= intravenous 3= subcutaneous 4= topical 5= inhalation 6= transdermal 7= rectal 8= intramuscular 9= sublingual 10= PEG 11= Other (specify)

Data type

integer

Route: If Other, please specify
Description

Route

Data type

text

Frequency (see Description)
Description

1= Daily 2= BID 3= TID 4= QID 5= QHS 6= CONT IV 7= PRN 8= Other (specify)

Data type

integer

Frequency: If Other, please specify
Description

Frequency

Data type

text

Indication
Description

Indication

Data type

text

Start Date
Description

Start Date

Data type

date

Stop Date OR Check If continuing at study end
Description

Stop Date

Data type

date

Was medication used to treat AE?
Description

AE Treatment

Data type

text

If Yes, specify event
Description

Specification

Data type

text

Similar models

Prior and Concomitant Medications: UIC Quality Improvement CRF

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
General Information
Protocol Title
Item
Protocol Title
text
Site Number
Item
Site Number
integer
Subject ID
Item
Subject ID
integer
Visit Date
Item
Visit Date
date
Prior and Concomitant Medications
Item
Were any Concomitant medications taken by the subject ___ days before or during the study? If Yes, record below.
text
Prior and Concomitant Medications
Item
If yes, how many days before?
integer
Prior and Concomitant Medications
Item
Prior and Concomitant Medications: No
boolean
Item Group
Medications
Medication
Item
Medication
text
Dose
Item
Dose
text
Route
Item
Route (see Description)
integer
Route
Item
Route: If Other, please specify
text
Frequency
Item
Frequency (see Description)
integer
Frequency
Item
Frequency: If Other, please specify
text
Indication
Item
Indication
text
Start Date
Item
Start Date
date
Stop Date
Item
Stop Date OR Check If continuing at study end
date
Item
Was medication used to treat AE?
text
Code List
Was medication used to treat AE?
CL Item
Yes (1)
CL Item
No (2)
Specification
Item
If Yes, specify event
text

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial